1. Diseases Resulting from Fungi and Yeasts
Kristy P. Gilbert, D.O.
February 8, 2005

2. Superficial mycoses AKA dermatophytes
Cause only stratum corneum, hair and nail infection
Three genera: Microsporum, Trichophyton, Epidermophyton
Division into: 1) tinea capitis, 2) tinea barbae, 3) tinea faciei, 4) tinea corporis, 5) tinea manus, 6) tinea pedis, 7) tinea cruris, 8)onychomycosis

3. Host factors Immunosuppressed pts- cancer, diabetes
AIDS, connective tissue disorders
Genetic susceptibility may be related to types of keratin or degree/mix of cutaneous lipids produced, cutaneous barrier compromise
Surface antigens-ABO system-one study of 108 culture proven dermatophytosis pts noted type A blood prone to chronic disease
Human steroid hormones can inhibit growth of dermatophytes (androgens like androstenedione)
One group believes this high susceptibility of Trichophyton rubrum & Epidermophyton floccosum to intrafollicular androstenedione is a reason why these species do not cause tinea capitis

4. Imidazoles
Clotrimazole, miconazole, sulconazole, oxiconazole, and ketoconazole
Mostly used for topical tx
Inhibit cytochrome P alpha-demethylase (an essential enzyme in ergosterol synthesis)
Ketaconazole has wide spectrum against dermatophytes, yeasts, and some systemic mycoses
Ketaconazole has the potential for serious drug interactions and a higher incidence of hepatotoxicity during long-term daily therapy

5. Allylamines Naftifine, terbinafine, butenafine
Inhibites squalene epoxydation
Terbinafine has less activity against Candida species in vitro studies then triazoles, but is effective clinically
Terbinafine is ineffective in the oral tx of tinea versicolor but is effective topically
Few drug interactions have been reported
Bioavailability is unchanged in food
Hepatotoxicity, leukopenia, severe exanthems, and taste disturbances uncommon, but should be monitored for clinically and by lab testing if continuous dosing over 6 weeks

6. Polyene
Nystatin
Irreversibly binding to ergosterol-an essential component of fungal cell membranes

7. Triazoles Itraconazole, Fluconazole Affect P450 system
Numerous drug interactions occur
Need to know pt’s current meds
Broadest spectrum to dermatophytes and Candida species, and Malassezia furfur
Itraconazole is fungistatic- food increases its absorption , antacids and gastric acid secretion suppressors produce erratic or lowered absorption
Pulse dosing limits concern over lab abnormalities
Fluconazole’s absorption is unaffected by food

8. Tinea Capitis Occurs chiefly in schoolchildren
Boys more frequently than girls; except epidemics caused by Trichophyton tonsurans where there is equal frequency
Divided into inflammatory and non-inflammatory
Tinea capitis can be caused by all pathogenic dermatophytes except Epidermophyton floccosum and T. concentricum
In U.S. most caused by T. tonsurans

9. Tinea Capitis

10. Noninflammatory M. audouinii infections present as the classic form
Characterized by multiple scaly lesions (“gray-patch”), stubs of broken hair
Over past 30 yrs, M. audouinii infections are being replaced by increasing numbers of “black-dot” ringworm, caused primarily by T. tonsurans and occasionally by T. violaceum
In the U.S. T. tonsurans is the most common cause

11. Noninflammatory Tinea Capitis
“Black dot” ringworm, caused by T. tonsurans & occasionally T. violaceum presents as multiple areas of alopecia studded with black dots representing infected hairs broken off at or below the surface of the scalp

13. Black dot tinea

14. Black dot ringworm caused by Trichophyton tonsurans

15. Inflammatory Usually caused by M. canis
Can be caused by T. mentagrophytes, T. tonsurans, M. gypsem, or T. verrucosum
M. canis begin as scaly, erythematous, papular eruptions with loose and broken-off hairs, followed by varying degrees of inflammation
A localized spot accompanied by pronounced swelling, with developing bogginess and induration exuding pus develops- kerion celsii
A delayed type hypersensitivity reaction to fungal elements
With extensive lesions fever, pain, and regional lymphadenopathy may occur

16. Kerion
Kerion may be followed by scarring and permanent alopecia in areas of inflammation and suppuration
Systemic steroids for short periods will greatly diminish the inflammatory response and reduce the risk of scarring

17. Kerion: inflammatory rxn of tinea capitis caused by Microsporum canis or Trichophyton mentagrophytes

18. Permanent scarring alopecia post-kerion

19. Kerion: red, oozing, hairless plaque

20. Favus Rare in the U.S. Most severe form of dermatophyte hair infection
Most frequently cause by T. schoenleinii
Hyphae and air spaces seen within hair shaft
Bluish white fluorescence under Wood’s light
Thick, yellow crusts composed of hyphae and skin debris (‘scutula’)
Scarring alopecia may develop

21. Favus with scarring alopecia and scutula

22. Scarring after favus infection

23. Etiology
Tinea capitis can be cause by any one of several species: T. tonsurans, M. audouinii (human to human), and M. canis (animals to human)
Endothrix types-T. tonsurans (black-dot ringworm) and T. violaceum
Ectothrix found on scalp are T. verrucosum & T. mentagrophytes, M. canis

24. Diagnosis Wood’s light
Ultraviolet of 365 nm wavelength is obtained by passing a beam through a Wood’s filter composed of nickel oxide-containing glass
A simple form is the 125-volt purple bulb
Fluorescent-positive infections are caused by :T. schoenleinii, M. canis, M. audouinii, M. distortum, M. ferrugineum
Hairs infected with T. tonsurans, T. verrucosum, & T. violaceum and others of endothrix do not fluoresce
The fluorescent substance is pteridine

25. Diagnosis KOH Scales or hairs cleared with it can still be cultured
Two or three loose hairs are removed
Hairs are placed on slide with a drop of 10-20% solution of KOH
A cover slip is applied, specimen is warmed until hairs are macerated
Examine under low, then high power
Scales or hairs cleared with it can still be cultured

26. DTM
DTM contains cycloheximide to reduce growth of contaminants and a colored pH indicator to denote the alkali-producing dermatophytes
Some clinically relevant nondermatophyte fungi are cycloheximide sensitive (Candida tropicalis, Scopulariopsis brevicaulis, Cryptococcus neoformans, Pseudoallescheria boydii, Trichosporon beigelii and Aspergillus spp.)

28. Ectothrix type in Microsporum canis-note small spores around hair shaft

29. Endothrix spores in hair with Trichophyton tonsurans

30. Endothrix in T. scoenleinii showing characteristic bubbles of air

31. Endothrix infection, (low-power KOH mount): arthroconidia noted within hair shaft
Endothrix infection (high-power KOH mount) showing total hair shaft involvement

33. T. tonsurans
This microoraganism grows slowly in culture to produce a granular or powdery yellow to red, brown, or buff colony
Crater formation with radial grooves may be produced
Microconidia may be seen regularly
Dx confirmed by the fact that cultures grow poorly or not at all without thiamine

34. T. mentagrophytes
Culture growth is velvety or granular or fluffy, flat or furrowed, light buff, white, or sometimes pink
Back of the culture can vary from buff to dark red
Round microconidia borne laterally and in clusters confirm dx within 2 weeks
Spirals are sometimes present
Macroconidia may be seen

35. T. verrucosum
Growth is slow and cannot be observed well for at least 3 weeks
Colony is compact, glassy, velvety, heaped or furrowed, and usually white, but may be yellow or gray
Chlamydospores (round swellings along the hyphal structures) are present in early cultures
Microconidia may be seen

36. M. audouinii
Gross appearance shows a slowly growing, matted, velvety, light brown colony
Back of which is reddish brown to orange
Under microscope a few large multiseptate macroconidia (macroaleuriospores) are seen
Microconidia (microaleuriospores) in a lateral position on hyphae are clavate
Racquet mycelium, chlamydospores, and pectinate hyphae are seen sometimes

37. M. canis
Culture shows profuse, fuzzy, cottony, aerial mycelia tending to become powdery in the center
Color is buff to light brown
Back of colony is lemon to orange-yellow
Numerous spindle-shaped multiseptate microconidia and thick-walled macroconidia are present
Clavate microconidia are found along with chlamydospores and pectinate bodies

39. Treatment
Griseofulvin of ultramicronized form, 10 mg/kg/day, is the daily dose recommended for children
Grifulvin V is the only oral suspension available for children unable to swallow tablets-dose is 20 mg/kg/day
Tx should continue for 2-4 months, or for at least 2 weeks after negative microscopic and culture examinations are obtained
Griseofulvin does not primarily affect the delayed type hypersensitivity reaction responsible for the inflammation in kerion
For this, systemic steroids, to minimize scarring, can be given simultaneously

40. Treatment Terbinafine -effective for Trichophyton infections
-3-6mg/kg/day for 1 to 4 weeks
-Microsporum infections may require larger doses and longer courses of therapy
Itraconazole
Fluconazole
Selenium Sulfide or Ketoconazole shampoo as an adjunct

42. Tinea Barbae AKA Tinea sycosis, barber’s itch Uncommon
Occurs chiefly among those in agriculture
Involvement is mostly one-sided on neck or face
Two clinical types are: deep, nodular, suppurative lesions; and superficial, crusted, partially bald patches with folliculitis

43. Tinea Barbae Superficial crusted type
mild pustular folliculitis with broken-off hairs (T. violaceum) or without broken-off hairs (T. rubrum)
Affected hairs are loose, dry, and brittle
When extracted bulb appears intact

44. Tinea Barbae
Deep type
Caused mostly by T. mentagrophytes or T. verrucosum
Swellings are usually confluent and form diffuse boggy infiltrates with abscesses
Pus may be expressed
Lesions are limited to one part of face or neck in men

45. Diagnosis-Tinea Barbae
Clinical
Confirmed by microscopic findings and by standard culture techniques
Rarely, Epidermophyton floccosum may cause widespread verrucous lesions known as verrucous epidermophytosis

46. Verrucous epidermophytosis from Epidermphyton floccosum

47. Complete resolution after 48 days of Griseofulvin

48. Differential Diagnosis
Sycosis vulgaris (staphlococcal folliculitis)-lesions are pustules and papules, pierced in the center by a hair, which is loose and easily extracted after suppuration has occurred
Contact dermatitis
Herpes infections

49. Tinea barbae-Trichophyton mentagrophytes

52. Treatment-Tinea Barbae
Oral antifungals are required
Topical agents as adjunctive therapy
Micronized or ultramicronized griseofulvin orally: dosage of 500–1000 mg or mg respectively
Tx usually for 4-6 weeks

53. Treatment-Tinea Barbae
Other orals that have been effective: ketoconazole, fluconazole, itraconazole, and terbinafine
Topical antifungals should be applied from the beginning of tx
Affected parts should be bathed thoroughly in soap and water
Healthy areas that are not epilated may be shaved or clipped
When kerion is present a short course of systemic steriod therapy may help reduce inflammation and risk of scarring

54. Tinea Faciei Fungal infection of the face (apart from the beard)
Must have high index of suspicion
Mistaken for seborrheic dermatitis, contact dermatitis, lupus, or photosensitive dermatosis
Erythematous, slightly scaling, indistinct borders are usually seen (best location for KOH scrapings)
Typical annular rings are usually lacking & lesions are exquisitely photosensitive
Usually caused by T. rubrum, T. mentagrophytes, or M. canis

55. Tinea faciei (Microsporum canis) in a child

56. Treatment Topical antifungals
If fungal folliculitis is present, oral medication is required
Oral griseofulvin administered for 2-4 weeks, as well as fluconazole, itraconazole, or terbinafine are all effective particularly in combination with topical therapy

57. Tinea Corporis(Tinea Circinata)
All superficial dermatophyte infections of the skin except the scalp, beard, face, hands, feet, and groin
Sites of predilection are neck, upper and lower extremities, and trunk
Characterized by one or more circular, sharply circumscribed, slightly erythematous, dry, scaly, usually hypopigmented patches
Advancing scaling edge is usually prominent

58. Tinea corporis in a child, caused by Microsporum canis

59. Tinea corporis (Trichophyton rubrum)
Note sharp margins and central clearing

60. Tinea Corporis
In some cases concentric circles form rings in one another, making intricate patterns (tinea imbricata)
Widespread tinea corporis may be the presenting sign of AIDS

61. Tinea corporis: large gyrate plaque with advancing border, perhaps worsened by diapering

62. Histopathology Better ways to make diagnosis
But if compact orthokeratosis is found in a section, a search for fungal hyphae should be performed
This is diagnostic

63. Etiology-Tinea Corporis
Microsporum canis, T. rubrum, T. mentagrophytes- most common
T. rubrum is is the most common dermatophyte in the U.S. and worldwide
T. tonsurans has experienced a dramatic rise as a cause of tinea corporis as it has for tinea capitis
In children, M. canis is the cause of the “moist” type of tinea circinata

64. Epidemiology
Tinea corporis is frequently seen in children-particularly those exposed to animals with ringworm (M. canis), especially CATS, dogs and less commonly, horses and cattle
In adults excessive perspiration is the most common factor
Personal history or close contact with tinea capitis or tinea pedis is another important factor
Incidence is especially high in hot, humid areas of the world

65. Treatment-Tinea Corporis
When tinea corporis is caused by T. tonsurans, M. canis, T. mentagrophytes, or T. rubrum; griseofulvin, terbinafine, itraconazole, and fluconazole are all effective
The ultra-micronized form may be used at a dose of mg once/day for 4-6 weeks
This dose may be increased to twice daily if needed
Terbinafine, itraconazole, and fluconazole are effective
Terbinafine at 250 mg/day for two weeks
Itraconazole 200 mg B.I.D. for one week
Fluconazole 150 mg once/week for 4 weeks

66. Treatment When only 1-2 patches occur, topical tx is effective
Most are between 2-4 weeks with twice daily use
Econazole, ketaconazole, oxiconazole, and terbinafine may be used once daily
With terbinafine the course can be shortened to 1 week

67. Treatment Creams are more effective than lotions
Sulconazole may be less irritating in folded areas
Castellani paint (which is colorless if made without fuchin) is very effective
Salicylic acid 3-5%, or half-strength Whitfield’s ointment, both standbys 30 yrs ago, are rarely used today
Addition of a low-potency steroid cream during the initial 3-5 days of therapy can decrease irritation rapidly without compromising the effectiveness of the antifungal

68. Other Forms of Tinea Corporis
Trichophytic Granuloma or Perifollicular Granuloma or Majocchi’s Granuloma or Tinea Incognito
A deep, pustular type of tinea circinata resembling a carbuncle or kerion observed on the glabrous skin
A circumscribed, annular, raised, crusty, and boggy granuloma
Follicles are distended with viscid purulent material
Most frequently on the shins or wrists

69. Majocchi’s granuloma H&E pale blue-staining fungal hyphae within hair shaft

70. Majocchi’s granuloma: PAS reveals multiple organisms that have replaced a fragment of hair shaft embedded in a sea of neutrophils

71. Tinea Imbricata (Tokelau)
Superficial fungal infection limited to southwest Polynesia, Melanesia, Southeast Asia, India, and Central America
Characterized by concentric rings of scales forming extensive patches with polycyclic borders
Small macular patch splits in center and forms large, flaky scales attached at the periphery
Resultant ring spreads peripherally and another brownish macule appears in the center and undergoes the process again

72. Tinea Imbricata
When fully developed the eruption is characterized by concentrically arranged rings or parallel undulating lines of scales overlapping each other like shingles on a roof (imbrex means shingle)
Causative fungus is T. concentricum
TOC is griseofulvin- in same form as for tinea corporis
Other options are terbinafine, fluconazole, and itraconazole
Several courses of therapy may be needed
May need to remove patient from hot, humid environment

73. Tinea imbricata in New Guinea native

74. Tinea imbricata: concentric rings of scale caused by T. concentricum

75. Tinea Cruris AKA jock itch Most common in men
On upper and inner thighs
Begins as a small erythematous and scaling or vesicular and crusted patch
Spreads peripherally and partly clears in the center
Penoscrotal fold or sides of scrotum are seldom involved; penis not involved

76. Tinea cruris in a man

77. Tinea cruris in a woman

79. Etiology-Tinea Cruris
T. mentagrophytes & E. floccosum & T. rubrum usual cause
Frequently associated with tinea pedis b/c of contaminated clothing
Heat and high humidity
Tight jockey shorts!

80. Treatment Reduce perspiration and enhance evaporation from crural area
Keep as dry as possible by wearing loose underclothing
Plain talcum powder or antifungal powders
Specific topical and oral treatment is same as that described under tinea corporis

81. Tinea in diaper area

82. Tinea Pedis AKA athlete’s foot Most common fungal disease(by far)
Primary lesions often are macerated with occasional vesiculation, and fissures between the toes
Extreme pruritus

83. Tinea pedis showing interdigital scalping
T. mentagrophytes

84. Interdigital scaling with vesiculation caused by T. mentagrophytes

85. Dermatophytosis of the soles
Trichophyton mantagrophytes

86. Acute vesiculobullous eruption on sole caused by Trichophyton mentagrophytes

87. TP-Trichophyton rubrum
T. rubrum causes the majority of cases
Produces a relatively noninflammatory type of dermatophytosis characterized by a dull erythema and pronounced scaling involving the entire sole and sides of feet
Producing a moccasin or sandal appearance

88. Tinea pedis and onychomycosis in father/son pair.
Father shows classic moccasin distribution of tinea pedis and son shows distal subungual onychomycosis

89. Tinea manus
Tinea infection of hands that is dry, scaly, and erythematous may occur
Suggestive of infection with T. rubrum
Other areas are frequently affected at the same time

90. Trichophyton rubrum infections

91. Differential diagnosis
Allergic contact or irritant dermatitis-especially occupational
Pompholyx
Atopic dermatitis
Psoriasis
Lamellar dyshidrosis
Eczematoid or dyshidrotic lesions of unknown cause on hands should prompt a search for clinical evidence of dermatophytosis of feet etc.

92. Fungus filaments under KOH mount

93. Mosaic fungus

94. Prophylaxis Hyperhidrosis is a predisposing factor
Dry toes after bathing
Tolnaftate powder or Zeasorb medicated powders for feet
Plain talc, cornstartch, or rice powder may be dusted into socks and shoes to keep feet dry

95. Treatment Topical antifungals
With significant maceration wet dressings or soaks with solutions such as aluminum acetate, one part to 20 parts of water
Anti-inflammatory effects of corticosteroids are markedly beneficial
Topical antibiotic ointments effective against gram-negative organisms (gentamicin), in tx of the moist type of interdigital lesions
In ulcerative type of gram-negative toe web infections, systemic floxins are needed

96. Treatment
Keratolytic agents, such as salicylic acid, lactic acid lotions, and Carmol are therapeutic when fungus is protected by a thick layer of overlying skin (i.e. soles)
Griseofulvin is only effective against dermatophytes
When infection is caused by T. mentagrophytes, griseofulvin does not decrease inflammatory reaction

97. Treatment- dosing
Griseofulvin in ultramicronized particles taken orally in doses of mg daily
Dosage for children is 10 mg/kg/day
Period of treatment depends on response
Repeated KOH scrapings and culture should be negative
Recommended adult doses for newer agents: terbinafine, 250 mg/day for 2 weeks; itraconazole, 200 mg twice daily for 1 week; fluconazole, 150 mg once weekly for 4 weeks

98. Onychomycosis (Tinea Unguium)
Onychomycosis encompasses both dermatophyte and non-dermatophyte nail infections
Represents up to 30% of diagnosed superficial fungal infections
Etiologic agents are: Epidermophyton, Microsporum, and Trichophyton fungi

99. Onychomycosis Four classic types:
1) distal subungual onychomycosis: primarily involves distal nail bed and hyponychium, with secondary involvement of underside of nail plate of fingernails and toenails

100. Onychomycosis caused by Trichophyton rubrum

101. Trichophyton mentagrophytes
2) white superficial onychomycosis (leukonychia trichophytica.) This is an invasion of the toenail plate on the surface of the nail
It is produced by T.mentagrophytes, species of Cephalosporium and Aspergillus, and Fusarium oxysporum fungus

102. Onychomycosis
3) Proximal subungual onychomycosis: involves the nail plate mainly from proximal nail fold
It is produced by T. rubrum & T. megninii and may be an indication of HIV infection
4) Candida onychomycosis involves all the nail plate; it is due to Candida albicans and is seen in patients with chronic mucocuataneous candidiasis
Associated paronychia
Adjacent cuticle is pink, swollen, and tender
Fingernails > toenails

103. Onychomycosis caused by Candida albicans in mucocutaneous candidiasis

104. Onychomycosis
Onychomycosis caused by T. rubrum is usually a deep infection
Disease usually starts at distal corner of nail and involves the junction of nail and its bed
First a yellowish discoloration occurs, which may spread until entire nail is affected
Beneath discoloration nail plate becomes loose from nail bed

105. Gradually entire nail becomes brittle and separated from its bed due to piling up of keratin subungually
Nail may break off, leaving an undermined remnant that is black and yellow from dead nail and fungi that are present

106. B: Superficial white onychomycosis
A: Distal subungal, onychomycosis occurring simultaneously with superficial white onychomycosis
B: Superficial white onychomycosis

107. Differential Allergic contact dermatitis Psoriasis Lichen planus
20 nail dystrophy
Darier’s disease
Reiter’s disease
Norwegian scabies
Non-dermatophyte onychomycosis

108. Treatment PO terbinafine, fluconazole, and itraconazole
Griseofulvin continued until nails are clinically normal
Low success rates 15-30% for toenails and 50-70% for fingernails
Griseofulvin does not tx nail disease caused by candida
3% Thymol in EtOH

110. Candidiasis
Candida proliferates in both budding and mycelial forms in outer layers of the stratum corneum where horny cells are desquamating
It does not attack hair, rarely involves nail, and is incapable of breaking up the stratum corneum
It is largely an opportunisitic organism
Moisture promotes its growth
Lip corners
Body folds

111. Diagnosis
Demonstration of the pathogenic yeast C. albicans establishes the diagnosis
Under microscope KOH prep may show spores and pseudomycelium
Culture on Sabouraud’s glucose agar shows a growth of creamy, grayish, moist colonies in about 4 days
In time colonies form small, root-like penetrations into agar

113. Mycelium and spores of Candida albicans

114. KOH mount from infant with thrush showing pseudohyphae and yeast forms
Candidiasis
KOH mount from infant with thrush showing pseudohyphae and yeast forms

115. Topical Anti-candidal Agents
These include, but are not limited to: clotrimazole (Lotrimin, Mycelex), econazole (Spectazole), ketaconazole (Nizoral), miconazole (MonistatDerm Lotion, Micatin), oxiconazole (Oxistat), sulconazole (Exelderm), naftifine (Naftin), terconazole (vaginal candidiasis only), cicloprox olamine (Loprox), butenafine (Mentax), nystatin, and topical amphotericin B lotion
Terbinafine has been reported to be less active against Candida species by some authors

116. Oral Candidiasis (Thrush)
Newborn infection may be acquired from contact with vaginal tract of mother
Grayish white membranous plaques are found on surface
Base of plaques are moist, reddish, and macerated
Diaper areas is especially susceptible to this
Most of intertriginous areas and even exposed skin may be involved

117. Oral candidiasis (Thrush)
Frequently infection extends onto angles of the mouth to form perleche (seen in elderly, debilitated, and malnourished patients, and diabetics)
It is often the first manifestation of AIDS
Is present in nearly 100% of all untreated patients with full-blown AIDS
“Thrush” in an adult with no known predisposing factors warrants a search for other evidence of infection with HIV, such as lymphadenopathy, leukopenia, or HIV antibodies in serum

118. Thrush with extension to vermilion border

119. Treatment
Babies with thrush may be allowed to suck on a clotrimazole suppository inserted into the slit tip of a pacifier four times a day for 2-3 days
An adult can let tablets of clotrimazole or Mycelex troches dissolve in the mouth
Fluconazole, mg/day for 5-10 days with doubling the dose if it fails, or Itraconazole, 200 mg daily for 5-10 days with doubling the dose if it fails-both are available in liquid forms

121. Perleche AKA angular cheilitis
Maceration with transverse fissuring of oral commissures
Soft, pinhead-sized papules may appear
Involvement is bilateral-usually

122. Perleche

123. Perleche Analogous to intertrigo elsewhere
Similar changes may be seen in riboflavin deficiency, and iron deficiency anemia
Identical fissuring occurs in persons with malocclusion caused by ill-fitting dentures and in the aged whom atrophy of alveolar ridges has occurred
Seen in children who drool, lick their lips, or suck their thumb

124. Treatment
If due to C. albicans, anti-candidal creams and lotions can be used
Glycemic control in diabetes
Antibiotic topical meds are used when a bacterial; infection is present
If due to vertical shortening of lower third of the face, dental or oral surgical intervention may help
Injection of collagen into depressed sulcus at the oral commissure may be helpful
Vytone!!

125. Candidal Vulvovaginitis
Pruritus, irritation, and extreme burning
Labia may be erythemtous, moist, and macerated and cervix hyperemic, swollen, and eroded, showing small vesicles on its surface
Vaginal discharge is not usually profuse but is frequently thick and tenacious
May develop during pregnancy, in diabetes, or secondary to therapy with a broad- spectrum antibiotic
Recurrent vulvovaginal candidiasis has been associated with long-term tamoxifen tx

126. Candidal Vulvovaginitis
Candidal balanitis may be present in an uncircumcised sexual partner
If not recognized, repeated reinfection of a partner may occur
Diagnosis is by clinical symptoms and findings as well as demonstration of fungus via KOH microscopic exam & culture
Tx is frustrating & disappointing due to recurrences
Oral fluconazole 150 mg times 1 dose; Fluconazole, 100mg/day for 5-7 days, itraconazole, 200 mg/day for 2-3 days are other options

128. Treatment
Topical options include miconizole (Monistat cream), nystatin vaginal suppositories or tablets (Mycostatin), or clotrimazole (Gyne-Lotrimin or Mycelex G) vaginal tablets inserted once daily for 7 days

129. Candidal Intertrigo
Pinkish intertriginous moist patches are surrounded by a thin, overhanging fringe of somewhat macerated epidermis (“collarette” scale)
May resemble tinea cruris, but usually there is less scaliness and a greater tendency to fissuring
Topical anti-candidal preparations are usually effective
Recurrence is common

131. Pseudo Diaper Rash
In infants, C. albicans infection may start in perianal region and spread over entire area
Dermatitis is enhanced by maceration produced by wet diapers
Diaper friction may contribute to skin irritation and compromised function of stratum corneum
Suspected by finding involvement of folds and occurrence of many small erythematous desquamating “satellite” or “daughter” lesions scattered around edges

132. Congenital Cutaneous Candidiasis
Infection of an infant during passage through birth canal
Eruption usually noted within first few hrs of delivery
Erythematous macules progress to thin-walled pustules, which rupture, dry, and desquamate within a week
Lesions are usually widespread, involving trunk, neck, and head, at times palms and soles, including nail folds
Oral cavity and diaper area are spared

133. Congenital Cutaneous Candidiasis
Differential dx: listeriosis, syphilis, staphylococcal and herpes infections, ETN, transient neonatal pustular melanosis, miliaria rubra , drug eruption, congenital icthyosiform erythroderma (neonatal pustular disorders)
If suspected early amniotic fluid, placenta, and cord should be examined for evidence of infection
Infants with disease limited to skin have favorable outcomes

134. Congenital Cutaneous Candidiasis
Disseminated infection is suggested by (1) birth weight <1500g (2) evidence of respiratory distress or labs indicating neonatal sepsis (3) tx with broad-spectrum antibiotics (4) extensive instrumentation during delivery or invasive procedures in neonatal period (5) positive systemic cultures, or (6) evidence of an altered immune response
Infants with congenital cutaneous candidiasis with any of these 6 criteria would be considered for systemic antifungal therapy

137. Perianal Candidiasis Frequently entire GI tract is involved
Can be precipitated by oral antibiotic therapy
Perianal dermatitis with erythema, oozing, and maceration is present
Psychogenic etiology is more common than is candidiasis
Differential dx: psoriasis, seborrheic dermatitis, streptococcal and staphylococcal infections, contact dermatitis, and extramammary Paget’s disease
Fungicides, meticulous cleansing of perianal region after bowel movements, topical corticosteroids and antipruritics (Atarax)

139. Candidal Paronychia
Cushion-like thickening of paronychial tissue, slow erosion of lateral borders of nails, gradual thickening and brownish discoloration of nail plates, and development of pronounced transverse ridges
Frequently only one nail
A secondary mixed bacterial infection can occur with those who frequently have hands in water or who handle moist objects; cooks, dishwashers, bartenders, nurses, canners, etc

140. Candidal Paronychia
Manicuring nails sometimes is responsible for mechanical or chemical injuries leading to infection
Ingrown toenails with chronic paronychia
Seen in pts with diabetes
Avoid chronic moisture exposure; get diabetes under control
Oral fluconazole once weekly or pulse dose itraconazole should be effective
Topical therapy should continue for 2-3 months to prevent recurrence

141. Erosia Interdigitalis Blastomycetica
Oval-shaped area of macerated white skin on web between and extending onto sides of fingers
With progression macerated skin peels off, leaving painful, raw,denuded area surrounded by a collar of overhanging white epidermis
Nearly always affects third web
Moisture beneath rings macerates skin and predisposes to infection
Also seen in diabetics, those who do housework, launderers, and others exposed to macerating effects of water and strong alkalis

143. Chronic Mucocutaneous Candidiasis
A heterogeneous group of patients whose infection with Candida is chronic but superficial
Onset before age 6
Onset in adult life may herald the occurrence of thymoma
When inherited an endocrinopathy is often found
Most cases have well-defined limited defects of cell-immunity
Oral lesions are diffuse and perleche and lip fissures are common

146. Systemic Candidiasis
High risk pts: pts with malignancies, AIDS, transplant pts requiring immunosuppressive drugs, pts on oral cortisone, pts who have had multiple surgical operations especially cardiac, pts with indwelling catheters, and heroin addicts
Initial sign is varied: FUO, pulmonary infiltrates, GI bleeding, endocarditis, renal failure, meningitis, osteomyelitis, endophthalmitis, peritonitis, or a disseminated maculopapular eruption

147. Systemic Candidiasis
Cutaneous findings are erythematous macules that become papular, pustular, and hemorrhagic, and may progress to necrotic, ulcerating lesions resembling ecthyma gangrenosum
Deep abscesses may occur
Trunk and extremities are usual sites of involvement
Proximal muscle tenderness is a common finding

148. Systemic Candidiasis
If candida is cultured within the first week of life there is a high rate of systemic disease
There is a 50% chance of systemic disease if 1 or more cultures is positive
Mortality has declined from 80% in the 1970’s to 40% in the 1990’s because of early empiric antifungals and better prophylaxis

149. THE END